- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $4,677.35 / $11,481.54
| Facility | | $1,621.81 | $4,677.35 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,778.28 / $4,466.84
| Professional | | $1,479.11 | $1,778.28 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $12,022.64 / $26,915.35
| Facility | | $4,466.84 | $12,022.64 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,238.72 / $4,265.80
| Professional | | $1,513.56 | $2,238.72 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $4,786.30 / $13,489.63
| Facility | | $323.59 | $4,786.30 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,630.27 / $5,623.41
| Professional | | $1,621.81 | $2,630.27 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,162.28 / $10,232.93
| Facility | | $851.14 | $3,162.28 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,137.96 / $3,981.07
| Professional | | $1,479.11 | $2,137.96 | $3,981.07 |